Inspection Reports for Ignite Medical Resort Dyer LLC
1532 CALUMET AVENUE, DYER, IN, 46311
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2025, found the facility in compliance with no deficiencies cited. Earlier inspections showed a mixed pattern with several citations related primarily to care planning, medication management, infection control, and emergency preparedness, including issues with tube feeding verification, PPE use, and emergency communication plans. Complaint investigations occasionally substantiated deficiencies, particularly involving resident care such as pressure ulcer treatment, timely physician notification, and proper use of PPE, but many complaints were found unsubstantiated. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The facility’s record shows some improvement in recent months, with the last two inspections in June 2025 showing compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
519% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
92% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00459895 completed on June 5, 2025.
Complaint Details
Investigation of Complaint IN00459895 completed on June 5, 2025; facility found in compliance.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Re-Inspection
Census: 92
Capacity: 100
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/15/2025.
Findings
At this Post Survey Revisit, Ignite Medical Resort Dyer LLC was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 100
Census: 92
Generator capacity: 175
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00458971 and IN00459895. Complaint IN00458971 had no deficiencies cited, while complaint IN00459895 resulted in federal/state deficiencies related to tube feeding management.
Complaint Details
Complaint IN00458971 - No deficiencies related to the allegations are cited. Complaint IN00459895 - Federal/State deficiencies related to tube feeding management were cited.
Findings
The facility failed to ensure proper verification of G-tube placement and residual checks prior to bolus feeding for 3 residents (Residents D, C, and E). Additionally, the facility did not flush the G-tube after feeding and failed to document residual amounts for these residents. Staff education and audits were planned to address these issues.
Deficiencies (2)
Failed to ensure G-tube placement and/or residual was checked prior to instilling a bolus feeding and failed to flush the tube after feeding.
Failed to document the amount of G-tube residual for 3 of 3 residents reviewed for tube feeding.
Report Facts
Census Bed Type - SNF: 96
Census Bed Type - Residential: 26
Total Census: 122
Medicare Census: 49
Other Payor Census: 47
Tube feeding volume: 300
Tube feeding volume: 175
Flush volume: 225
Tube feeding frequency: 4
Tube feeding frequency: 5
Dates missing residual documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report |
| Director of Nursing | Interviewed regarding tube feeding procedures and deficiencies | |
| LPN 2 | Licensed Practical Nurse | Observed administering tube feeding without flushing after feeding |
| Nurse 1 | Nurse | Observed administering bolus feeding without verifying placement or checking residual |
| CNO | Chief Nursing Officer | Conducted audits and education related to tube feeding procedures |
Inspection Report
Census: 93
Capacity: 100
Deficiencies: 0
Date: May 15, 2025
Visit Reason
An Emergency Preparedness Survey and a Preoccupancy Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483 Subpart B, respectively. The visit was also in conjunction with the Life Safety Code Recertification Survey.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as Requirements for Participation in Medicare/Medicaid and Life Safety Code standards. No deficiencies were cited.
Report Facts
Certified beds: 100
Census: 93
Square footage: 75
Inspection Report
Census: 93
Capacity: 100
Deficiencies: 8
Date: May 15, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/15/2025 to assess compliance with federal and state regulations including emergency preparedness requirements and life safety code standards.
Findings
The facility was found not in compliance with emergency preparedness requirements including policies on volunteers and staffing, communication plans, emergency officials contact information, primary and alternate communication means, and emergency preparedness testing requirements. Additionally, life safety code deficiencies were identified including improper use of power strips, lack of testing and maintenance documentation for patient care related electrical equipment, and inadequate oxygen storage/transfilling room conditions.
Deficiencies (8)
Failed to ensure emergency preparedness policies and procedures include the use of volunteers and emergency staffing strategies.
Failed to ensure emergency preparedness communication plan includes names and contact information for staff, entities, physicians, LTC facilities, and volunteers.
Failed to ensure emergency preparedness communication plan includes contact information for emergency officials including State Licensing and Certification Agency and Office of the State Long-Term Care Ombudsman.
Failed to ensure emergency preparedness communication plan includes primary and alternate means for communication with staff and emergency management agencies.
Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to ensure flexible cords and adapters were not used as a substitute for fixed wiring; power strips were daisy-chained.
Failed to conduct required maintenance and maintain documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Failed to ensure oxygen storage/transfilling room was used properly with adequate space and fire barrier separation.
Report Facts
Certified beds: 100
Census: 93
Power strips daisy-chained: 3
Oxygen containers: 5
Portable refillable tanks: 3
Oxygen carts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Named in relation to exit conference and plan of correction |
| Director of Environmental Services | Interviewed and acknowledged deficiencies; involved in corrective actions and monitoring | |
| LPN | Licensed Practical Nurse | Interviewed regarding oxygen storage/transfilling room access |
Inspection Report
Recertification
Census: 26
Deficiencies: 17
Date: Apr 29, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including a Recertification and State Licensure Survey and Investigation of Complaints IN00455936, IN00456419, IN00456626, IN00456640, IN00457582, and IN00458078.
Complaint Details
Complaints IN00455936, IN00456419, IN00456626, IN00456640, IN00457582, and IN00458078 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. Several deficiencies were identified including issues with resident self-administration of nebulizer treatments, notification of changes to physicians, care plan development, medication administration errors, food labeling and storage, and documentation completeness.
Deficiencies (17)
Failed to ensure residents who self-administer nebulizer treatments were assessed for safe self-administration (Resident 29).
Failed to ensure physician was notified of elevated blood sugars, held medications, and medication refusals for 3 residents (Residents 52, 154, 264).
Failed to notify resident's responsible party in writing related to hospital transfer (Resident 79).
Failed to accurately complete Minimum Data Set (MDS) assessment related to terminal prognosis and hospice care (Resident 44).
Failed to develop and implement comprehensive care plan for edema, compression glove use, and oxygen (Resident 60).
Failed to ensure professional standards of quality were maintained related to CNA placing tube feeding pump on hold (Resident 73).
Failed to ensure bruises were assessed and monitored, constipation symptoms monitored, edema monitored, and medications held per blood pressure parameters (Residents 91, 255, 60, 27, 264).
Failed to assist resident to see an eye doctor (Resident 29).
Failed to ensure G-tube flushes were instilled via gravity for medication administration (Resident 202).
Failed to ensure residents received necessary respiratory care including oxygen therapy per physician orders (Resident 60).
Medication error rate exceeded 5% due to insulin pen not primed and incorrect dose administered (Resident 66).
Failed to ensure medications were kept in a locked medication cart at all times during medication administration (Resident 66).
Failed to keep kitchen clean and in good repair related to food not labeled and dated (Main Kitchen).
Failed to maintain complete and accurate medical record related to medication administration documentation and medication orders (Resident 42).
Failed to ensure service plans were signed, completed, and updated with changes including hospice services (Resident 7).
Failed to complete transfer/discharge form for resident transfers (Resident 7).
Failed to monitor blood pressure for resident with PRN blood pressure medication order (Resident 2).
Report Facts
Census: 26
Medication error rate: 7.69
Medication administration opportunities: 26
Medication errors observed: 2
Residents reviewed for MDS: 27
Residents reviewed for service plans: 7
Residents reviewed for transfer forms: 7
Residents reviewed for PRN blood pressure monitoring: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed report cover page |
| LPN 1 | Involved in medication administration errors including insulin pen priming and medication security | |
| LPN 2 | Observed administering G-tube flush incorrectly and re-educated | |
| LPN 3 | Provided information about bruising on Resident 91 | |
| LPN 4 | Indicated nurses did not check blood pressure for Resident 2 | |
| Director of Nursing | Director of Nursing | Provided multiple interviews and explanations related to deficiencies and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview regarding medication documentation |
| Director of Social Services | Director of Social Services | Provided interview regarding vision and dental care coordination |
| Kitchen Manager | Kitchen Manager | Provided interviews and policies related to food labeling and storage |
| Assisted Living Director | Assisted Living Director | Provided interview and corrective action related to service plans and transfer forms |
| Nurse Consultant | Nurse Consultant | Provided interview regarding CNA scope of practice for tube feeding pump |
| CNA 1 | Placed tube feeding pump on hold outside scope of practice |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on April 29, 2025.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00450991 plus unrelated deficiencies completed on March 4, 2025.
Complaint Details
Investigation of Complaint IN00450991; paper compliance review found facility in compliance.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 2
Date: Mar 3, 2025
Visit Reason
This visit was conducted for the investigation of four complaints (IN00450991, IN00453717, IN00453895, and IN00453976) regarding the facility's compliance with federal and state regulations.
Complaint Details
Complaint IN00450991 was substantiated with deficiencies cited. Complaints IN00453717, IN00453895, and IN00453976 had no deficiencies related to the allegations cited.
Findings
The investigation found federal/state deficiencies related to complaint IN00450991, specifically regarding failure to notify the physician timely of a medication delay and failure to use correct Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions. No deficiencies were found related to the other complaints. The facility submitted plans of correction for the cited deficiencies.
Deficiencies (2)
Failed to ensure the physician was notified in a timely manner of a medication that was unavailable for 1 of 3 residents reviewed (Resident E).
Failed to ensure correct Personal Protective Equipment (PPE) was used by staff member when providing care to a resident on Enhanced Barrier Precautions (Resident G).
Report Facts
Census: 123
Skilled Nursing Facility beds: 93
Residential beds: 30
Medicare census: 51
Other payor census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding medication notification and PPE use deficiencies |
| CNA 1 | Staff member involved in PPE deficiency |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00450726 plus unrelated deficiencies completed on January 9, 2025.
Complaint Details
Investigation of Complaints IN00450726 was reviewed for paper compliance.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00447372, IN00450096, IN00450148, IN00450163, and IN00450726) at Ignite Medical Resort Dyer LLC.
Complaint Details
The investigation involved five complaints. Four complaints (IN00447372, IN00450096, IN00450148, IN00450163) had no deficiencies related to the allegations. Complaint IN00450726 was substantiated with federal/state deficiencies cited at F686 and F880.
Findings
The facility was found deficient related to Complaint IN00450726 involving failure to provide necessary treatment and services to promote healing of a pressure ulcer and failure to use correct Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions. Other complaints had no deficiencies related to their allegations.
Deficiencies (2)
Failure to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing, including interventions not in place and treatment not completed as ordered.
Failure to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to a resident on Enhanced Barrier Precautions.
Report Facts
Census Bed Type - SNF: 98
Census Bed Type - Residential: 30
Total Census: 128
Census Payor Type - Medicare: 51
Census Payor Type - Other: 47
Total Census Payor: 98
Pressure ulcer size: 1.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report |
| Wound Nurse 3 | Involved in wound care treatment and interview regarding pressure ulcer | |
| Wound Nurse 4 | Interviewed regarding resident's pressure ulcer and wound care | |
| LPN 1 | Licensed Practical Nurse | Observed providing care without proper PPE |
| LPN 2 | Licensed Practical Nurse | Observed providing care without proper PPE |
| CNA 4 | Certified Nursing Assistant | Assisted resident to turn during wound care |
| Director of Nursing | DON | Interviewed regarding wound care and corrective actions |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 5
Date: Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00443720, IN00444029, IN00444812, IN00445316, IN00445480, IN00445567, IN00446247, and IN00446301) related to the facility.
Complaint Details
The investigation was triggered by multiple complaints alleging deficiencies related to notification of changes, ADL assistance, skin condition monitoring, IV catheter maintenance, and clinical documentation. Some complaints had deficiencies cited while others did not.
Findings
The facility was found deficient in several areas including failure to promptly notify responsible parties of significant changes, incomplete activities of daily living assistance, inadequate assessment and monitoring of bruising, improper maintenance and monitoring of IV catheters, and incomplete clinical documentation related to falls and treatments.
Deficiencies (5)
Failed to ensure the resident's responsible party was promptly notified after a significant change in status related to IV site placement and medication changes for 1 of 3 residents.
Failed to ensure activities of daily living (ADLs) were completed for residents needing assistance related to long fingernails for 1 of 5 residents.
Failed to ensure areas of bruising were assessed and monitored for 1 of 3 residents reviewed for skin conditions non-pressure related.
Failed to ensure a peripheral intravenous (IV) catheter was maintained, monitored, and assessed for patency for 2 of 3 residents reviewed for IV catheters.
Failed to ensure clinical records were complete and accurately documented related to falls for 1 of 3 residents and failed to document treatments were completed as ordered for 1 of 3 residents reviewed for pressure ulcers and skin conditions.
Report Facts
Census: 110
Skilled Nursing Facility beds: 80
Residential beds: 30
Medicare census: 48
Other payor census: 32
Dates of survey: 3
Medication Administration Record missing sign-outs: 3
Residents audited weekly: 5
Residents audited weekly: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report |
| Chief Nursing Officer | Interviewed regarding deficiencies in notification, IV catheter monitoring, fall documentation, and treatment sign-outs | |
| Wound Nurse | Interviewed regarding treatment completion and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
Paper compliance review to the investigation of multiple complaints (IN00443720, IN00444812, IN00445316, IN00445480, IN00445567, IN00446247, and IN00446301) completed on November 14, 2024.
Complaint Details
The visit was related to multiple complaint investigations, all of which were reviewed for paper compliance and found to be in compliance.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442142.
Complaint Details
Complaint IN00442142 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00442142 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 83
Census Bed Type - Residential: 28
Total Census: 111
Census Payor Type - Medicare: 38
Census Payor Type - Other: 45
Total Census Payor: 83
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00438865, IN00439371, and IN00439585 plus an unrelated review completed on August 8, 2024.
Complaint Details
The visit was related to complaint investigations IN00438865, IN00439371, and IN00439585. The facility was found to be in compliance based on the paper review.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 121
Capacity: 121
Deficiencies: 8
Date: Aug 5, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00438865, IN00439338, IN00439371, IN00439585, and IN00439697) regarding regulatory compliance and resident care at Ignite Medical Resort Dyer LLC.
Complaint Details
The investigation was triggered by complaints IN00438865, IN00439338, IN00439371, IN00439585, and IN00439697. Deficiencies were substantiated for complaints IN00438865, IN00439371, and IN00439585. Complaints IN00439338 and IN00439697 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to provide and document sufficient transfer information, inaccurate Minimum Data Set (MDS) assessments, incomplete comprehensive care plans, failure to administer antibiotics and monitor blood glucose as ordered, inadequate fall investigations, incorrect posting of nurse staffing information, lack of appropriate behavior management for a resident with dementia, and improper use of personal protective equipment during wound care.
Deficiencies (8)
Failed to provide and document sufficient information for a resident transferred to the hospital Emergency Room.
Failed to ensure Minimum Data Set (MDS) assessments were accurately completed related to falls, medications, and behaviors.
Failed to develop and implement individualized comprehensive care plans related to knee immobilizer and behaviors.
Failed to ensure a resident received necessary care related to antibiotics not administered, blood sugar not obtained, and physician notification not completed.
Failed to ensure thorough fall investigation including root cause and appropriate intervention.
Failed to ensure posted nurse staffing information was current and included only staff scheduled for long term care.
Failed to ensure a resident with dementia received appropriate treatment and services related to behaviors, including lack of interdisciplinary team input, behavior identification, care plans, and documentation of interventions.
Failed to ensure correct Personal Protective Equipment (PPE) was used when providing pressure ulcer treatments.
Report Facts
Survey dates: 2024-08-05 to 2024-08-08
Census SNF beds: 96
Census Residential beds: 25
Total census: 121
Medicare census: 49
Other payor census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report |
| Director of Nursing | Interviewed regarding transfer documentation, MDS accuracy, behavior documentation, and fall investigation | |
| LPN 2/MDS | Licensed Practical Nurse | Interviewed regarding MDS assessment coding |
| LPN Wound Nurse 3 | Licensed Practical Nurse | Observed providing wound care without proper PPE |
| LPN Wound Nurse 4 | Licensed Practical Nurse | Observed providing wound care without proper PPE |
| Social Service Director | Interviewed regarding behavior care planning and social service involvement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00431978 completed on June 18, 2024.
Complaint Details
Investigation of Complaint IN00431978; paper compliance review completed with findings of compliance.
Findings
Ignite Medical Resort of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 99
Capacity: 126
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00431978 and IN00435661, regarding allegations related to residents' medical record access and other issues.
Complaint Details
Complaint IN00431978 was substantiated with federal/state deficiencies cited related to the allegations. Complaint IN00435661 was not substantiated with no deficiencies cited.
Findings
The facility failed to provide timely access to medical records for 2 of 3 residents reviewed, resulting in a deficiency related to the right to access/purchase copies of records. Additionally, the facility failed to ensure proper use of Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) for a resident with a urinary catheter, resulting in infection prevention and control deficiencies.
Deficiencies (2)
Failed to provide residents' medical records to the resident/POA in a timely manner after a request was made for 2 of 3 residents reviewed.
Failed to ensure correct use of Personal Protective Equipment (PPE) when emptying a urinary catheter drainage bag for a resident on Enhanced Barrier Precautions (EBP).
Report Facts
Census: 99
Total Capacity: 126
Survey Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding medical record request process and delays | |
| LPN 2 | Interviewed regarding Enhanced Barrier Precautions education and signage | |
| LPN 3 | Interviewed regarding education on EBP and infection control | |
| LPN Infection Control Nurse | Interviewed regarding missed EBP signage and PPE cart for resident with urinary catheter | |
| CNA 1 | Observed and interviewed regarding failure to don gown when emptying urinary catheter drainage bag |
Inspection Report
Re-Inspection
Census: 100
Capacity: 100
Deficiencies: 0
Date: May 1, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/28/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The certified portion of Ignite Medical Resort Dyer LLC, first floor, was found in compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility was fully sprinklered and met all fire safety standards at the time of this visit.
Report Facts
Facility capacity: 100
Census: 100
Inspection Report
Life Safety
Census: 100
Capacity: 100
Deficiencies: 12
Date: Mar 28, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 03/28/2024 to assess compliance with Medicare/Medicaid participation requirements and life safety codes.
Findings
The facility was found in compliance with Emergency Preparedness requirements but had multiple deficiencies related to life safety code including delayed egress door malfunction, incomplete kitchen hood suppression coverage, missing fire alarm visual inspection documentation, incomplete fire watch policy, sprinkler system documentation issues, corridor door hold open device misuse, HVAC combustion air intake obstruction, oversized trash receptacles in corridors, generator load testing documentation deficiencies, improper use of flexible cords and power strips, and improper storage of liquid oxygen containers.
Deficiencies (12)
Delayed egress locking arrangement failed to release lock within required time, affecting approximately 30 residents and staff.
Kitchen hood extinguishing system did not provide complete coverage for cooking equipment producing grease-laden vapors.
Fire alarm system lacked documentation of required semi-annual visual inspection.
Fire alarm system out-of-service policy lacked required contact information for Indiana Department of Health.
Sprinkler system lacked documentation of required internal pipe inspections.
Sprinkler system out-of-service policy lacked required contact information for Indiana Department of Health.
Corridor door to Unit Nursing Manager's office was propped open with a door stop instead of using approved hold open devices.
Laundry room fuel-fired dryers lacked proper fresh air intake due to closed grates obstructing air flow.
Trash receptacles in corridor exceeded allowed capacity and density requirements.
Generator load testing documentation lacked required load percentage information.
Flexible cords were used as substitutes for fixed wiring and power strips were improperly used in patient rooms and offices.
Liquid oxygen container stored in resident room was not separated by required fire barriers and door was not self-closing or secure.
Report Facts
Certified beds: 100
Census: 100
Residents affected: 30
Trash receptacle capacity: 33
Trash receptacle capacity: 20
Liquid oxygen max capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marnie Davisson | LNHA, VP of Operations | Signed report and plan of correction |
Inspection Report
Routine
Census: 28
Capacity: 126
Deficiencies: 13
Date: Mar 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of multiple complaints including IN00424703, IN00424731, IN00426055, IN00426751, IN00427100, IN00427561, and IN00429885.
Complaint Details
This visit included investigation of complaints IN00424703, IN00424731, IN00426055, IN00426751, IN00427100, IN00427561, and IN00429885. Deficiencies related to complaints IN00424703, IN00424731, IN00426751, and IN00429885 were cited.
Findings
The facility was found to have multiple deficiencies including failure to ensure proper medication self-administration orders, misappropriation prevention, ADL care provision, activity programming, quality of care, respiratory care, pain management, medication management, infection control, medication storage and labeling, clinical record completeness, and COVID-19 immunization compliance.
Deficiencies (13)
Failure to ensure residents had Physician's Orders and assessments for self-administration of medications.
Failure to implement a system to prevent misappropriation of resident property related to narcotic medication documentation.
Failure to complete Significant Change Minimum Data Set (MDS) assessment after hospice services were initiated.
Failure to provide ADL assistance including showers, nail care, shaving, and oral care to dependent residents.
Failure to ensure ongoing activity program for cognitively impaired dependent residents.
Failure to assess and monitor bruising, ensure treatment for excessive diarrhea, and arrange transportation for surgical appointments.
Failure to ensure oxygen was set at the correct flow rate for residents on respiratory care.
Failure to administer pain relief medication as ordered related to narcotic medication availability.
Failure to ensure medications were properly stored and labeled, including unlabeled insulin vial and loose pills in medication carts.
Failure to ensure medication error rate was less than 5%, including crushing extended release tablets, improper inhaler use, and insulin administration errors.
Failure to maintain complete clinical records related to meal consumption intake documentation.
Failure to implement infection prevention and control program including improper disposal of used lancet in garbage can.
Failure to ensure COVID-19 vaccination education, consent/refusal documentation, and vaccine administration were properly conducted and documented.
Report Facts
Survey dates: 6
Residents reviewed for self-administration: 5
Medication error rate: 10.34
Residents reviewed for medication error: 6
Residents reviewed for unnecessary medications: 5
Residents reviewed for ADL care: 6
Residents reviewed for activities: 2
Residents reviewed for quality of care: 2
Residents reviewed for respiratory care: 4
Residents reviewed for clinical records: 6
Residents reviewed for infection control: 1
Residents reviewed for COVID-19 immunization: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaints IN00424703, IN00424731, IN00426751, and IN00429885.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00422105 completed on November 27, 2023.
Complaint Details
Complaint IN00422105 was investigated and found to be in compliance based on paper review.
Findings
Ignite Medical Resort Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 127
Deficiencies: 4
Date: Nov 27, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00422105 related to federal/state deficiencies concerning family notification, transfer documentation, dementia treatment, and resident records.
Complaint Details
Complaint IN00422105 - Federal/state deficiencies related to family notification failures, transfer documentation issues, dementia treatment inadequacies, and incomplete resident records.
Findings
The facility failed to notify a resident's family of behaviors, medication changes, and hospital transfers; failed to provide and document sufficient transfer information; failed to ensure appropriate treatment and care planning for a resident with dementia; and failed to maintain complete and accurate resident records including documentation of hospital returns and discharge events.
Deficiencies (4)
Failed to ensure a resident's family was notified of behaviors, medication changes, and transfers to the Emergency Room.
Failed to provide and document sufficient information for a resident transferred to the hospital Emergency Room related to Transfer Forms/assessments not completed.
Failed to ensure a resident with dementia received appropriate treatment and services, including lack of interdisciplinary team input, no updated care plan, and ineffective interventions.
Failed to maintain complete and accurate resident records, including no documentation of resident's return from Emergency Room, no documentation of appeal of Notice of Medicare Non-Coverage (NOMNC), and lack of documentation of discharge events.
Report Facts
Census: 98
Total Capacity: 127
Residents with Behaviors Reviewed: 5
Residents Reviewed for Transfer Documentation: 1
Residents Reviewed for Dementia Treatment: 3
Residents Reviewed for Medical Records: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | General Manager | Signed the report and plan of correction. |
| Director of Nursing | Interviewed regarding family notification and transfer documentation failures. | |
| Social Service Director | Interviewed regarding discharge planning and documentation. | |
| Employee 1 | Provided observation and interview regarding Resident B's behaviors. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
Paper compliance review related to the complaint investigations IN00414266 and IN00417299 completed on October 10, 2023.
Complaint Details
The visit was related to complaint investigations IN00414266 and IN00417299; the facility was found in compliance.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 82
Capacity: 109
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414266 and IN00417299 at Symphony of Dyer.
Complaint Details
Complaint IN00414266 and Complaint IN00417299 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations of the complaints were cited. However, an unrelated deficiency was identified regarding the administration of unnecessary medications to one resident.
Deficiencies (1)
Facility failed to ensure a resident was free from unnecessary medications, related to a medication administered when the blood pressure was out of the prescribed parameter for 1 of 1 resident reviewed.
Report Facts
Census Bed Type - SNF/NF: 7
Census Bed Type - SNF: 75
Census Bed Type - Residential: 27
Total Licensed Capacity: 109
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 7
Census Payor Type - Other: 57
Total Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | Administrator | Signed the report and identified as the Administrator |
| Director of Nursing | Director of Nursing | Indicated that the Midodrine medication had been given incorrectly |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00407458 and IN00408541 completed on June 21, 2023.
Complaint Details
The visit was related to complaint investigations IN00407458 and IN00408541, with paper compliance confirmed.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 99
Deficiencies: 2
Date: Jun 21, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00404644, IN00406233, IN00407458, IN00407900, IN00408525, IN00408541, IN00409951, and IN00410943) and included a COVID-19 Focused Infection Control Survey.
Complaint Details
The investigation involved multiple complaints. Complaints IN00407458 and IN00408541 had federal/state deficiencies cited at F692 and F842 respectively. Other complaints had no deficiencies related to the allegations.
Findings
The facility was found deficient in maintaining acceptable nutritional status for a resident due to supplements not administered as ordered and incomplete meal consumption records. Additionally, the facility failed to maintain complete and accurate resident medical records related to treatment order charting for a resident with a skin condition. Some complaints were substantiated with deficiencies cited, while others had no deficiencies related to allegations.
Deficiencies (2)
Failed to ensure a resident maintained acceptable nutritional status related to supplements not administered as ordered and incomplete meal consumption records.
Failed to ensure a resident's clinical record was complete and accurately documented related to treatment order charting not updated for a resident with non-pressure related skin conditions.
Report Facts
Census: 73
Total Capacity: 99
Medication Administration Record (MAR) missed doses: 17
Medication Administration Record (MAR) missed doses: 15
Meal Consumption Log missing documentation: 18
Deficiency completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | Administrator | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403720 completed on March 14, 2023.
Complaint Details
Investigation of Complaint IN00403720 completed on March 14, 2023; facility found in compliance.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 100
Deficiencies: 1
Date: Mar 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00401636 and IN00403720.
Complaint Details
Complaint IN00401636 - No deficiencies related to the allegations are cited. Complaint IN00403720 - Federal/State deficiencies related to the allegations are cited at F808.
Findings
No deficiencies were found related to Complaint IN00401636. For Complaint IN00403720, a federal/state deficiency was cited for failure to have a physician's order in place for a resident's therapeutic diet.
Deficiencies (1)
Failure to have a Physician's Order in place for a resident's therapeutic diet for 1 of 3 residents reviewed for diet (Resident C).
Report Facts
Census Bed Type - Total: 100
Census Payor Type - Total: 73
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding lack of physician's diet order for Resident C | |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding chart audit and diet order entry error for Resident C |
Inspection Report
Life Safety
Census: 68
Capacity: 100
Deficiencies: 1
Date: Feb 23, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Certification and State Licensure Survey were conducted by the Indiana Department of Health on 02/23/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey found the facility not in compliance due to storage of items in two of three interior fire escape stairways, which could interfere with egress.
Deficiencies (1)
Items stored in 2 of 3 interior fire escape stairways interfered with egress, including approximately 50 cardboard boxes of PPE and a resident room bathroom door stored in stairwells.
Report Facts
Certified beds: 100
Census: 68
Cardboard boxes stored in C5 stairwell: 50
Cardboard boxes stored in A5 stairwell: 20
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | Administrator | Named as Administrator and signer of the report |
| Maintenance Director | Interviewed regarding storage in stairwells and agreed it could interfere with egress |
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 02/23/23.
Findings
Symphony of Dyer was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Inspection Report
Census: 22
Deficiencies: 16
Date: Feb 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including a Recertification and State Licensure Survey and the Investigation of Complaints IN00398131 and IN00399166.
Complaint Details
Complaint IN00398131 was substantiated with deficiencies cited at F677 and F692. Complaint IN00399166 was substantiated with deficiencies cited at F684 and F697.
Findings
The survey identified multiple deficiencies including failure to ensure proper medication self-administration assessments, notification of changes, accuracy of assessments, care plan participation, ADL care, quality of care, bowel/bladder incontinence management, respiratory care, pain management, unnecessary drug use, antibiotic stewardship, nutrition/hydration documentation, personnel training, evaluation documentation, and clinical record completeness.
Deficiencies (16)
Facility failed to ensure residents had physician orders and assessments for self-administration of medications.
Facility failed to notify resident of medication changes.
Facility failed to ensure accuracy of Minimum Data Set related to insulin and anticoagulant medication use.
Facility failed to ensure residents were invited to care planning conferences and care plans were reviewed and revised appropriately.
Facility failed to provide adequate ADL care including nail care, shaving, showers, and timely toileting.
Facility failed to monitor signs and symptoms of constipation, assess areas of discoloration, complete fall follow-up, and document discharge location.
Facility failed to ensure oxygen was set at correct flow rate and nasal cannula properly placed.
Facility failed to ensure pain management was provided consistent with resident's pain level.
Facility failed to ensure medications were not used for excessive duration and monitored adequately related to medicated wipes and blood pressure parameters.
Facility failed to ensure residents did not receive unnecessary psychotropic medications without adequate indications.
Facility failed to ensure antibiotic stewardship by appropriate use and monitoring of antibiotic therapy.
Facility failed to ensure annual dementia training was completed for all required staff.
Facility failed to ensure sufficient staff with current first aid certification were scheduled.
Facility failed to complete semi-annual evaluations and record weights twice a year for residents.
Facility failed to ensure physician orders were obtained for resident diets.
Facility failed to maintain complete and accurate clinical records related to discharge documentation.
Report Facts
Census: 22
Deficiency counts: 13
Medication administration delays: 14
Weight loss: 44.6
Insulin units: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Named in medication error related to insulin administration |
| Megan Matula | Administrator | Signed report and involved in interviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaints IN00398131 and IN00399166.
Complaint Details
Investigation of Complaints IN00398131 and IN00399166 was completed and found in compliance.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Report Facts
Complaint Investigation IDs: IN00398131 and IN00399166
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394614 completed on November 17, 2022.
Complaint Details
Investigation of Complaint IN00394614 completed on November 17, 2022; facility found in compliance.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 67
Capacity: 93
Deficiencies: 2
Date: Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394614, which was substantiated with federal and state deficiencies cited.
Complaint Details
Complaint IN00394614 was substantiated with deficiencies cited at F689 (Free of Accident Hazards/Supervision/Devices) and F919 (Resident Call System).
Findings
The facility was found deficient in ensuring residents had assistive devices to prevent accidents and injuries, specifically related to fall risk interventions for one resident, and failed to ensure call lights were functioning properly in two resident rooms.
Deficiencies (2)
Failure to ensure a resident had assistive devices in place to prevent accidents and injuries related to fall risk interventions.
Failure to ensure residents' call lights were functioning for residents to call for staff assistance when needed.
Report Facts
Residents reviewed for falls/accidents: 3
Resident rooms observed for call light availability and functioning: 21
Residents affected by call light deficiency: 2
Residents affected by fall risk deficiency: 1
Census Bed Type - Total: 93
Census Payor Type - Total: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Matula | Administrator | Signed the report and involved in the inspection process. |
| Director of Nursing | Director of Nursing | Interviewed regarding fall risk interventions and bed positioning for Resident D. |
| Maintenance Director | Maintenance Director | Interviewed regarding call light system maintenance and repairs. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00386616, IN00388244, and IN00388395, plus an unrelated completed review on August 31, 2022.
Complaint Details
The visit was related to complaint investigations IN00386616, IN00388244, and IN00388395. The facility was found to be in compliance based on the paper review.
Findings
Symphony of Dyer was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 6
Date: Aug 30, 2022
Visit Reason
This visit was for the investigation of four substantiated complaints (IN00382587, IN00386616, IN00388244, and IN00388395) related to care planning, incontinent care, nutrition, respiratory care, medication storage, and resident records.
Complaint Details
Complaints IN00382587, IN00386616, IN00388244, and IN00388395 were substantiated with deficiencies cited related to care planning, incontinent care, nutrition, respiratory care, medication storage, and resident records.
Findings
The facility was found deficient in developing comprehensive care plans for discharge and hospice services, timely incontinent care, monitoring nutritional intake and supplement orders, ensuring CPAP treatment was provided as ordered, proper medication storage, and maintaining accurate and complete resident records including documentation of appeals after Notice of Medicare Non-Coverage.
Deficiencies (6)
Failed to develop comprehensive care plans for discharge planning and hospice services for 2 of 7 residents reviewed.
Failed to provide timely incontinent care for a resident requiring extensive to dependent care.
Failed to ensure residents at nutritional risk received meals and/or monitoring, and physician orders for dietary supplements were complete.
Failed to ensure a resident requiring CPAP treatment received it as ordered; no documentation of refusals.
Failed to ensure medications were stored in a locked medication storage area; unlabeled and un-ordered medications found at resident bedside.
Failed to maintain accurate and complete resident records related to appeal status after Notice of Medicare Non-Coverage, late entry for bathing, and oxygen flow rate documentation.
Report Facts
Census Bed Type Total: 114
Census SNF: 76
Census Residential: 28
Census SNF/NF: 10
Census Medicare: 42
Census Medicaid: 10
Census Other: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Educated on ensuring medications are not left at bedside unless there is a self-administration assessment and physician order. | |
| CNA 1 | Involved in incontinent care observation and education on timely ADL care. | |
| Director of Nursing | Director of Nursing | Provided current policies, interviewed regarding CPAP use, medication storage, and documentation issues. |
| Unit Manager | Indicated no care plan developed for hospice services and removed unlabeled medications from resident room. | |
| Social Service Director | Indicated no care plan developed for discharge planning and discussed appeal of Medicare Non-Coverage. |
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